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Emergency Radiology in Bariatric Surgery
Magnus Sundbom, Ass Prof Head of Esophageal and Gastric Surgery Uppsala, 15th of May 2013
Case from Uppsala
• 39-year man, 50-kg weight loss after gastric bypass • Episodes with colicky pain
• Emergency laprotomy – Necrotic small bowel – Resection > 3m
• Short bowel syndrome • Long hospital stay, death
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Internal Hernia
• Entrapment of the small bowel • Warning signs
– Colicky pain – Laparoscopic operation – Maximum weight loss
• 1-2 years postop
High level of suspicion in all bariatric patients
Radiology
• Dilated prox small bowel • Normal distal loops
• Swirl sign
• Dilated excluded stomach
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End
Focus on two main areas
1. Why operate?
2. Changes in anatomy?
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Morbidly obese patients have
• High risk of comorbidities – Diabetes, sleep apnea, CHD
• Shortened life expectancy – 7 years at BMI>40
• Reduced quality of life – Spinal cord injury, cancer with metastasis
Indications for bariatric surgery
• Failed conservative treatment – Diet, medication, and others
• BMI>35 kg/m2 (100 kg) – Mean weight 130-160 kg
• 18-60 years
• Understand the life-long consequences
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Operative technique Gastric bypass (GBP) • Exclude the stomach
– Small gastric pouch – Quick passage into
the small bowel
• Laparoscopy – 94% av all GBPs – 2-day hospital stay
Weight loss during the first year
Johansson L, Roos M, Kullberg J, Weis J, Ahlström H, Sundbom M, Edén Engström B, Karlsson FA. Lipid Mobilization Following Gastric Bypass Examined by Magnetic Resonance Imaging. Obes Surg. 2008
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Results
• Weight loss of 14 BMI-units – 45-60 kg or 70% of previous overweight
• Reduced sleep apnea, CHD, mortality • Diabetes
– Remission in 65% of diabetics – 6 operations prevent 1 case of diabetes
• Improved quality of life – 92% of Uppsala patients satisfied at 10 years
Changes in anatomy
• Internal hernia – Behind Roux limb – Small bowel
• Enteroanastomosis
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Entero-enteroanastomosis
Defect often closed with suture or clips at present
Carucci L R et al. Radiology 2009;251:762-770
Herniation behind entero-enteroanastomosis
Most common! Distal bowel loops caught in hernia
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• Bariatric surgery helps morbidly obese – Comorbidity, life expectancy, QoL
• 10-fold increase in number of operations
Please help us find internal hernias!
Conclusion